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HomeMy WebLinkAboutBCOI-24-14- The Commonwealth of Massachusetts Town of tk,.,) YARMOUTH New and Renewal Certification of Inspection In accordance with the Massachusetts State Building Code,Section 110.7 Identify Name of Establishment Certificate No. Issued to Business Name:Seafood Sam's BCOI-24-14 Trade Name:Seafood Sam's Identify property address including street number,name,city or town,and county Certificate Expiration Located at 1006 ROUTE 28 November 30,2024 SOUTH YARMOUTH,MA 02664 Use Group Classification(s) Floor Occupancy_ Use Group Other 01st Floor 97 A-2 Restaurants,Night Clubs,or 97 Persons Allowable Occupant Load similar uses This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure,or portion thereof as herein specified has been inspected for general fire and line safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Munici al Chief Enri ue Arrascue Name of Municipal Building Mark G ate of Inspection 3 )51?IC 2_1- P 4 Commissioner 1 r, Signature of Municipal Fire Signature of Municipal Building � ate of Issuance 3!1Z/2 7 Chief Commissioner / .� : TOWN OF YARMOUTH (A' ! o ' ��. BUILDING DEPARTMENTk M TACrl i E 4'' f ,� =e e.•o..s« 1146 Route 28 South Yarmouth, MA 02664 508-398-2231 ext. 1260 1° . APPLICATION FOR CERTIFICATE OF INSPECTION January 5, 2024 PAYABLE UPON RECEIPT (X) Fee Required $100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: ( bp Cc L+- Name of Premises: Snc Tel: Sbelc . et` -3S-" • Purpose for which permit is used: °- c-ct-St. Li,e 1.du.u,-1 s-. t 6 % , , E C E I V E D License(s) or Permit(s) required for the premises by other governmental agencies: " '�" ° ' �. 1 License or Permit Agency FEB 05 2024 cI-Wk(LA T B U I L L N T v'k'L B y:___ Certificate to be issued to L1 kC ka.sw Tel: 4 -2.o' 1 -9 ‘ Address: '5 Owner of Record of Building te.vbe.-‘- Address 61 at `-1 e T a l .s W � ibil/ 1 P.iu� , \A L S4v a-r4- 'FL. 3 at 9 -1 Present Holder of Certificate �' 6 -j\A4)Lti -e-S-' J,Luct7v\ 0{-„ ,f5b44.)k-- Signature of person to whom Title Certificate is issued or his agent 7-- j 2 t ?� Date Email Address: 9&(cY\ ' t , Co n1 Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten (10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CA NOT ISSVf Y R CERTIFICATE OF INSPECTION. Certificate of Inspection # I �( a ---/ 04/01/2024-11/30/2024 AC012 0® CERTIFICATE OF LIABILITY INSURANCE DATE(MMDO/YYYY) 1/30/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ° CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNAME ACT RogersGray-SBC RogersGray,A Baldwin Risk Partner PHONE FAX 410 University Ave (A/c.No.Eat):781-208 8400 (A/C,No): Westwood MA 02090 E-MAIL ADDRESS: rgsbc@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC N License#:PC-514062 INSURER A:Massachusetts Retail Merchants INSURED SEAFSAM-02 INSURER B:Arbella Protection Insurance C 41360 Seafood Sam's of S.Yarmouth, Inc. dba Seafood Sam's INSURER C: 1006 Rte 28 INSURER D: South Yarmouth MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:449728358 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) B X COMMERCIAL GENERAL LIABILITY 8500054782 3/20/2023 3/20/2024 EACH OCCURRENCE $1,000,000 D GE TO RENTED CLAIMS-MADE X OCCUR PREMISES SES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECOT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: AUTOMOBILEUABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) B X UMBRELLA LIAB X OCCUR 4620091340 3/20/2023 3/20/2024 EACH OCCURRENCE $2,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $2,000,000 DED X I RETENTION$1n nnnOTH- $ A WORKERS COMPENSATION 014005032775124 1/1/2024 1/1/2025 X AND EMPLOYERS'UABIUTY STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE Y/N N/A E.L.EACH ACCIDENT $500,000 OFFICERJMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 B Liquor Liability 8500054782 3/20/2023 3/20/2024 Each Occurrence $1,000,000 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Main AU Q$(jD REPRESENTATIVE South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD